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CLINICAL MANAGEMENT GUIDELINES Trauma (blunt) Aetiology Blow to the eye: accidental (e.g. RTA, industrial, domestic, sports) or non-accidental (e.g. fist) Also known as ocular contusion Predisposing factors Usually unexpected but may be vocational (e.g. boxing) Symptoms Pain varies from mild to severe Epiphora Visual loss (variable) Photophobia Signs Mild cases (usually with good corrected vision) • eyelid swelling (oedema), ecchymosis (bruising) • conjunctival chemosis, subconjunctival haemorrhage • corneal abrasion Severe cases (usually with some loss of visual function) • infraorbital nerve anaesthesia (lower lid, cheek, side of nose, upper lip, teeth) may indicate orbital floor fracture • disturbance of ocular motility: restriction or diplopia due to tissue swelling or muscle tethering by orbital (‘blow-out’) fracture • enophthalmos (sunken eye) may also indicate orbital fracture • nasal bleeding (direct trauma, or could indicate skull fracture) • corneal oedema or laceration • AC: hyphaema (blood in aqueous), uveitis, flare and cells • traumatic mydriasis • iridodialysis (tearing of iris from its attachment to ciliary body) • lens: evidence of subluxation, cataract, capsule damage • IOP may be increased secondary to uveitis, or reduced because of scleral perforation (rupture of globe) • vitreous haemorrhage • commotio retinae, retinal detachment or dialysis • traumatic macular hole • globe rupture (full thickness wound of eye wall) • relative afferent pupillary defect (indicates traumatic optic neuropathy) Differential diagnosis Other causes of acute red eye Pre-septal cellulitis Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological Careful history required, including mechanism and time of injury Lid oedema: cold compress to ease swelling (GRADE*: Level of evidence=low, Strength of recommendation=strong) Pharmacological Systemic analgesia e.g. paracetamol, aspirin If there is significant tissue swelling: non-steroidal anti-inflammatory drug (e.g. ibuprofen) (GRADE*: Level of evidence=low, Strength of recommendation=strong) In cases of corneal abrasion consider topical antibiotic (GRADE*: Level of evidence=low, Strength of recommendation=weak) Management Category Management depends on severity of injury Mild cases: B2: alleviation or palliation; referral unnecessary Severe cases: Trauma (blunt) Version 11, Page 1 of 2 Date of search 20.07.15; Date of revision 18.12.15; Date of publication 05.02.16; Date for review 19.07.17 © College of Optometrists CLINICAL MANAGEMENT GUIDELINES Trauma (blunt) A2: first aid measures and emergency (same day) referral to A&E Possible management by Ophthalmologist Assessment and investigation including imaging (e.g. X-ray, CT, MRI) Treatment of globe rupture where present May require hospital admission Evidence base *GRADE: Grading of Recommendations Assessment, Development and Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm) Sources of evidence Alteveer J, Lahmann B. An evidence-based approach to traumatic ocular emergencies. Emergency Medicine Practice 2010;12(5):1-21 Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10 Lecuona K. Assessing and managing eye injuries. Community Eye Health. 2005;18(55):101-4 LAY SUMMARY The eye is well protected by the bony structures of the face that surround it (brow, cheek, nose) but it is sometimes injured by a direct blow, which is usually accidental but is sometimes the result of an assault. In mild cases this often results in bruising and swelling of the tissues around the eye (a ‘black eye’) which resolves fully in time leaving no after-effects; painkillers may be the only treatment needed. In more severe cases one or more of the bones of the orbit (the bony cavity in which the eyeball sits) may be fractured and this may cause the eye or one of the muscles that moves it to be displaced. The blow to the eye may also damage the structures inside the eye and may cause internal bleeding. Such cases need to be referred as emergencies to the ophthalmologist. Trauma (blunt) Version 11, Page 2 of 2 Date of search 20.07.15; Date of revision 18.12.15; Date of publication 05.02.16; Date for review 19.07.17 © College of Optometrists